Immediate Implant in Area with Periapical Lesion?

Delayed implant. Extract, currette, graft. Come back another day for for the implant.

With the size of the lesion and location will be impossible to clean it out well to remove any problematic tissue. i would extract see if there is a perf on the buccal wall of the ridge open that clean it out graft it all close and wait 8 weeks before re-enter to place implant

Extract with delayed placement.

Delayed would be a conventional approach but this will lead you into losing bone in the all important crestal region. Besides, it may be impossible to adequately clean out the apical region enough to get good bone regeneration. One thing you could consider is to remove the tooth, then open flap the region, and do a buccal perforation in the apical region to enable you do a thorough clean out. Once you have done that then there should be little problem in placing an implant, then grafting in the apical and crestal regions. So instead of thinking conventional vs. delayed, it may be better to approach the case by trying to tip the biological scales in your favor. An All-in-One procedure might get you the best result.

This is the type of case that increases your failure rate. Extract the tooth, and d a very thorough job cleaning the periapical lesion. The fact that the cortical plate is intact is a plus, and means that you don't have to graft. Wait for complete soft tissue healing and then come back in a month or two and place your implant. You are less likely to run into complications from infection this way. Good luck!

It looks to me like there is minimum bone on the facial which will be lost during the extraction leading to a hole in the buccal plate. If an immediate implant fails then you may have to do the case over. Or maybe the patient will seek treatment in another office after you have refunded their payment. Neither one of these options sound good to me. I tend to me conservative and extract, clean out with rotary burs, graft and wait an appropriate time. I have a CT in office so I wait and take a new CT Scan. This removes a lot of the guessing about the bone available. I also use a surgical guide even on single implants. You can get a guide made from your Sim Plant or other software programs. Scan the patient or take an impression for the model, send to 3ddx or who every you want. They will set up a consultation time for you and a dentist to review the file before fabrication of the surgical guide. Using the guide makes the implant placement flapless in the majority of cases.

Extraction, currette ,antibiotic,after 6-8weeks put implant

I routinely perform extraction/immediate placement in these cases, especially when key walls are still present. Success requires two things. First, enough bone to get initial stability and, second, the ability to completely debride the crypt. In these cases, ablative lasers with side firing tips are the most important instrument I have. Then we employ autologous biologics to shape the immune response. Without a hard tissue laser and PRF, I would be hesitant to do this case simultaneously.

I am a great fan of extract + immediate placement, however, that is only legitimate after making a cost benefit analysis. What is the benefit of early placement? Preservation of the vertical height & prevention of a labial fenestration are certainly considerations, yet, they can be easily managed once the site has healed rather than being critical dominant issues at the day of extraction. There is adequate vertical bone for implant placement after a period of healing plus any crestal bone loss can be solved with soft tissue trickery after healing. ... so the ace up your sleeve maybe to allow a submerged implant to provide sufficient soft tissue overgrowth to allow papilla enhancement at stage 2 abutment connection/healing abutment. The aesthetic need for a rapid transition from wonky root to smiling temporary seems less pressing than taking on the risk of being accused of being too hasty should the implant fail for any of the pre-existing reasons, or worse, infection. Explain the benefits and risks to the patient in writing and let them decide: handsome v's disappointment within an aura of "if only we had waited". Me? All out and wait. If the tooth was a lateral or central, different drama as a temporary partial denture is a wonderful stage to avoid.

If you are doing a full arch case and plan to do an immediate provisional, would you abort the procedure because of one lesion like this in an arch? This is the type of lesion we see routinely in these types of cases and we cannot postpone the placement of implants and immediate restoration of an arch. In a single tooth replacement you have far greater leeway, but that's not an excuse to not learn how to place implants in these types of sites.

This is not an infection, but rather a well circumscribed peri-apical cyst. So the treatment is a bit different from the normal infected case. However, virtually all extraction/immediate implant cases we do are "infected" sites. They are either periodontal infections, or granulomatous lesions from failed endodontically treated teeth. There is no question that you can mitigate out the potential for complications and failures by extracting first and allowing it to heal. But upon extraction are you placing a bone graft? If so, don't the same rules and potential outcomes come into play for the graft as for the implant? By developing a paradigm to eliminate infections and protecting grafted areas you are, by it's very nature, developing a paradigm for safe placement of immediate implants. This is what we do on a daily basis in our practices, and with an outcome that is virtually identical to healed sites.

After thorough curettage, I have been irrigating sites like this with Clindamycin slurry (open a capsule of clindamycin into a small sterile bowl of saline, draw it into an irrigation syringe) before placing graft material and/or implant....any thoughts??

"By developing a paradigm to eliminate infections and protecting grafted areas you are, by it’s very nature, developing a paradigm for safe placement of immediate implants." I'm not sure that I follow. Sounds like you are saying you should extract and treat the bone to allow adequate healing and then place implants, but you are also saying that you do lots of immediate cases with good success. It sounds like you do lots of cases like these and have clinical experience with what will work and what won't. My concern is in general, the idea that the treatment plan has to be followed, regardless of what surprises we may run into clinically. Yes, we would like to be able to extract and place the implant today, but the bone may not be available......

My first post clearly delineates the two required parameters; enough bone for initial stability and complete debridement of the pathology. If you feel the need for local antibiotic use, the best for anaerobic bacteria is aqueous metronidazole (5mg/ml). For those of us who do full arch extractions, immediate implant placement with grafting of defects, if we did not have a successful paradigm for placing implants and bone grafts in infected sites, this treatment modality would have almost disappeared. Take some courses from the clinicians doing these cases and follow their protocols closely. Your perspective will change significantly and your patients will appreciate this new expertise. RJM

Extract Do not debride ! Wait 8 weeks Then any grafting or implant placement will be more predictable After a scan If you do immediate placement you might still lose the labial plate of bone with that case . Happens without infection in immediate placement !

Please Extract the tooth curette the region graft close the soft tissue do these work under AB coverage.And foget this location for implantation because there is always a risk for accecerbation of a sleeping infection which will prevent you from being succesfull .

I routinely treat these with the ND-Yag then graft. It has a deeper penetration then a curette or antibiotics. I've been burned by immediate placement see "retroperi-implantitis" which I feel is from the pigmented bacteria deeply seeded in the bone. Just my take.